This blog is totally independent, unpaid and has only three major objectives.
The first is to inform readers of news and happenings in the e-Health domain, both here in Australia and world-wide.
The second is to provide commentary on e-Health in Australia and to foster improvement where I can.
The third is to encourage discussion of the matters raised in the blog so hopefully readers can get a balanced view of what is really happening and what successes are being achieved.

Thursday, July 11, 2013

Here Is An Issue We Still Have Not Addressed. How Will We Record And Protect Mental Health Information In An Electronic Health Record?

Adam Kaplin, M.D., chief psychiatric consultant at Johns Hopkins Hospital in Baltimore, wants everyone to be aware that depression is the biggest killer of heart attack patients during the year after their surgery. Not smoking, not high cholesterol, but an insidious mental illness that, like other mental illnesses, has serious physical repercussions.

"Cardiologists should know that they need to pay extra attention to depressed patients because they're at much greater risk, since these diseases interact with each other," Kaplin says.

But how do they know which patients are depressed? Often they don't, unless the patients tell them.

Kaplin has struggled to share his patients' information with the other doctors who care for them, but has found institutional reluctance to facilitate that kind of sharing, even with an electronic health record system available.

And Johns Hopkins is not alone. Kaplin and fellow Hopkins researchers recently surveyed whether mental health information is being shared at the top 18 hospitals on the 2012 U.S. News and World Report ranking. Only 44 percent were storing their psychiatric records electronically at all, and only 28 percent were sharing those records with physicians outside psychiatry.

Moreover, the team found that sharing psychiatric information correlated with significantly lower patient readmission rates. Their study was published online in December in the International Journal of Medical Informatics.

If sharing is that rare at the top hospitals, despite the apparent favorable impact on care, it's safe to assume it's even rarer at the average hospital, Kaplin says. "There's still a tremendous stigma surrounding mental illness, and the only way we'll move forward is to start treating it like other somatic illness," he says. "We psychiatrists know that these illnesses are no different than hypertension or diabetes. They're chronic conditions, not personal weaknesses, and there is a biological basis to them."

The direct and indirect costs of mental illness and substance abuse are a huge toll on the overall health of the country. The National Alliance on Mental Illness estimates that the mental illness costs the economy $79 billion annually, including $63 billion in lost productivity. If indirect costs are included-for example, mentally ill people who lose their jobs, are underemployed or unemployed, the costs may be as much as $193.5 billion. The U.S. spends about $135 billion treating mental illness and addiction every year, not counting dollars spent on physical illnesses that are complicated by mental illness.

Until recently, behavioral health information (a blanket term covering both mental health and substance abuse treatment) has been sequestered by both law and common practice, and behavioral health professionals have guarded it jealously. With good reason: Patients who aren't assured of confidentiality might not be honest with their providers, or might avoid seeking treatment at all, because of the stigma surrounding problems of the mind.

"You could put my entire medical history on a billboard and I wouldn't care, but people with psychiatric conditions are in the worst position to understand what should be shared about their care," says John Houston, vice president of privacy and security at University of Pittsburgh Medical Center. "Lots of people with serious psych disorders are being appropriately cared for and able to be productive, but they are very concerned about people knowing they have some disorder or issue." His wife runs a large psychiatric hospital, which makes him unusually aware of the quandary inherent in sharing such sensitive information.

However, the need for coordinated care is overtaking the impulse to be secretive. Both the Office of the National Coordinator and the Substance Abuse and Mental Health Administration are funding projects to facilitate the sharing of behavioral health data with other providers.

Colorado's RHIO released a detailed plan last year for including behavioral health information in its statewide HIE. More than a third of Colorado adults report poor mental health.

In Illinois, the Behavioral Health Integration Project, part of the statewide health information exchange, is working with the state legislature to modify its unusually stringent confidentiality provisions. Harry Rhodes, directory of HIM excellence at AHIMA, who's on the HIE's privacy and security committee, says its research revealed that the process for a new patient evaluation can take up to 10 days because cautious providers exchange information via courier. "A lot of behavioral health is done by teams, so there's a lot of exchange," he says. When several providers tried using Direct protocols instead, evaluation time was reduced to two or three days.

Why has it been so difficult to share behavioral health data? The main reason is that it's hedged with legal safeguards. The laws are designed to maintain patient privacy except in life-or-death emergencies, but they also have had the effect of discouraging the use of computers to store information pertaining to mental health and substance abuse treatment.

Psychiatry and psychology are among the least automated sectors in health care. Solo and small practices are the norm, and most treatment involves listening and writing prescriptions. "The technology for psychiatry is a pen and an [electroconvulsive therapy] machine," Kaplin says. "We've been so far behind our brethren disciplines."

Glenn Martin, M.D., appreciates the irony that he is the head of the Interboro RHIO, a health information exchange for New York City and surrounding communities, while refusing to have electronic records in his small private psychiatry practice. "I'm happy to be a glutton for information," he says. "I will download but not upload," though he is willing to let his patients' primary care providers know when he has prescribed a medication.

Steven Daviss, M.D., chair of psychiatry at Baltimore Washington Medical Center and head of the EHR committee for the American Psychiatric Association, says many psychiatrists don't have enough Medicare and Medicaid patients to make it worthwhile to try to pursue federal EHR incentive payments. If they use a computer at all for the clinical side of their practice, it might be as simple as a Word document for each patient. And the upside of using a certified EHR-for example, the ability to quickly identify which patients are due for a medication check-is far outweighed by the fear of a security breach.

"Psychiatrists think more about data breaches than other physicians do," Daviss says. "We hear about breaches every day, and there's a concern that the technology is still too early to guarantee safety."

The APA backs electronic records for mental health, but only if patients have at least as much control over them as they do over paper records, and aren't forced into an "all or nothing" situation. "Electronic health record design and implementation should leverage technology to give more flexible approaches to access for sensitive information," according to the organization's position statement.

Within Daviss's institution, all providers have access to their patients' psych records. "Frankly, it would be hard to understand how a facility could do the work it needs to do if everyone can't access the information," he says. For example, a physician doing a diabetes evaluation would benefit from knowing that the patient has lost 20 pounds in the past month due to depression.

The University of Pittsburgh Medical Center also shares its psych data within the institution. Dealing with several layers of patient consent has been one of the most challenging issues, says Houston. In Pennsylvania, patients must give specific consent for each provider to see their information, and under the law they can also choose which information is disclosed. Because the EHR can't segment information that way, UPMC treats everything in a psych encounter as sensitive data. Houston isn't happy with that solution, but it's the best he can do for now. He would like to be able to distinguish truly sensitive information from information that ceases to be sensitive when taken out of the context of a psych encounter.

"It's important to know that a patient is being prescribed a drug, but the acute care setting doesn't need to know why," he says. "Methadone can be a painkiller as well as being used to treat addiction." All-or-nothing is a persistent problem, says Michael Lardiere, vice president for HIT and strategic development for the National Council for Community Behavioral Health, which is participating in several state pilots of behavioral health information exchange. "If you're a medical patient, you can't say, 'Send all my information except for the lab work from yesterday,' but laws allow patients to make that kind of decision about their behavioral health data. At this point, these systems don't give patients the granular control that the law says they can have."

"Many of the systems being built to facilitate sharing are leaving mental and behavioral health data out altogether, and that creates an issue," says Deven McGraw, director of the health privacy project at the Center for Democracy and Technology, Washington. While structured data fields could be flagged or blocked, much behavioral health data is in free text and difficult to flag.

One of SAMHSA's initiatives, Data Segmentation for Privacy (DS4P), is intended to address this issue, and it is testing the concept with the Department of Veterans Affairs, using metadata to signal the privacy level of behavioral health and other sensitive data.

Martin acknowledges that technology is lagging, but questions how much it matters, because if medical provider has enough information to coordinate care-for example, a complete medication list-he or she also has enough information to deduce a great deal about the patient's behavioral health situation. "The state of the art means that data granularity can't be guaranteed, but even if it could, who cares?" he says. "Once they see you have a lithium level, the cat's out of the bag."

To me this article is must not miss reading for both technologists and policy makers. We have not really properly addressed this problem at either of these levels.

As pointed out in the article - once you see measurements of Serum Lithium in the lab results you essentially know the individual has a major mental illness even if the diagnostic information is blocked.

I am not sure how that - or prescriptions for major psychiatric meds - can be excluded from an EHR in such a way as to have the patient confident to share the other important material that might be in the record.